Perioperative Management of Antihypertensive Agents: More Answers or More Questions?
Authors: Jason F. Shiffermiller, Christopher M. Whinney
Journal: Annals of Internal Medicine (2023)

EditorialsMay 2023Perioperative Management of Antihypertensive Agents: More Answers or More Questions?Jason F. Shiffermiller, MD, MPH, Christopher M. Whinney, MDJason F. Shiffermiller, MD, MPHDivision of Hospital Medicine, University of Nebraska Medical Center, Omaha, NebraskaSearch for more papers by this author, Christopher M. Whinney, MDDepartment of Hospital Medicine, Cleveland Clinic, Cleveland, OhioSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M23-0745 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The management of hypertension is a core aspect of the practice of medicine. Appropriate blood pressure control reduces the incidence of clinically relevant outcomes, including ischemic and hypertensive heart disease, chronic kidney disease, and stroke (1). However, optimal blood pressure management is more complicated in certain clinical situations, such as hypertensive emergency, acute ischemic or hemorrhagic stroke, and advanced age. The perioperative management of antihypertensive agents is one of these areas of clinical complexity. Perioperative continuation of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) has been shown to lead to intraoperative hypotension (2–4), although whether the continuation of these ...References1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:1269-1324. [PMID: 29133354] doi:10.1161/HYP.0000000000000066 CrossrefMedlineGoogle Scholar2. Roshanov PS, Rochwerg B, Patel A, et al. Withholding versus continuing angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers before noncardiac surgery: an analysis of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN prospective cohort. Anesthesiology. 2017;126:16-27. [PMID: 27775997] doi:10.1097/ALN.0000000000001404 CrossrefMedlineGoogle Scholar3. Hollmann C, Fernandes NL, Biccard BM. A systematic review of outcomes associated with withholding or continuing angiotensin-converting enzyme inhibitors and angiotensin receptor blockers before noncardiac surgery. Anesth Analg. 2018;127:678-687. [PMID: 29381513] doi:10.1213/ANE.0000000000002837 CrossrefMedlineGoogle Scholar4. Shiffermiller JF, Monson BJ, Vokoun CW, et al. Prospective randomized evaluation of preoperative angiotensin-converting enzyme inhibition (PREOP-ACEI). J Hosp Med. 2018;13:661-667. [PMID: 30261084] doi:10.12788/jhm.3036 CrossrefMedlineGoogle Scholar5. Mudumbai SC, Takemoto S, Cason BA, et al. Thirty-day mortality risk associated with the postoperative nonresumption of angiotensin-converting enzyme inhibitors: a retrospective study of the Veterans Affairs healthcare system. J Hosp Med. 2014;9:289-296. [PMID: 24799360] doi:10.1002/jhm.2182 CrossrefMedlineGoogle Scholar6. Marcucci M, Painter TW, Conen D, et al; POISE-3 Trial Investigators and Study Groups. Hypotension-avoidance versus hypertension-avoidance strategies in noncardiac surgery. An international randomized controlled trial. Ann Intern Med. 2023;176:605-614. doi:10.7326/M22-3157 LinkGoogle Scholar7. Sessler DI, Meyhoff CS, Zimmerman NM, et al. Period-dependent associations between hypotension during and for four days after noncardiac surgery and a composite of myocardial infarction and death: a substudy of the POISE-2 trial. Anesthesiology. 2018;128:317-327. [PMID: 29189290] doi:10.1097/ALN.0000000000001985 CrossrefMedlineGoogle Scholar8. Walsh M, Devereaux PJ, Garg AX, et al. Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension. Anesthesiology. 2013;119:507-515. [PMID: 23835589] doi:10.1097/ALN.0b013e3182a10e26 CrossrefMedlineGoogle Scholar9. Futier E, Lefrant JY, Guinot PG, et al; INPRESS Study Group. Effect of individualized vs standard blood pressure management strategies on postoperative organ dysfunction among high-risk patients undergoing major surgery: a randomized clinical trial. JAMA. 2017;318:1346-1357. [PMID: 28973220] doi:10.1001/jama.2017.14172 CrossrefMedlineGoogle Scholar10. Wijeysundera DN. Perioperative management of ACE inhibitor therapy: challenges of clinical decision making based on surrogate endpoints. J Hosp Med. 2018;13:724-726. [PMID: 30261089] doi:10.12788/jhm.3062 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAuthors: Jason F. Shiffermiller, MD, MPH; Christopher M. Whinney, MDAffiliations: Division of Hospital Medicine, University of Nebraska Medical Center, Omaha, NebraskaDepartment of Hospital Medicine, Cleveland Clinic, Cleveland, OhioDisclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-0745.Corresponding Author: Christopher M. Whinney, MD, Department of Hospital Medicine, Cleveland Clinic Lerner College of Medicine, 9500 Euclid Avenue, M8-13, Cleveland, OH 44195; e-mail, whinnec@ccf.org.This article was published at Annals.org on 25 April 2023. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoHypotension-Avoidance Versus Hypertension-Avoidance Strategies in Noncardiac Surgery Maura Marcucci , Thomas W. Painter , David Conen , Vladimir Lomivorotov , Daniel I. Sessler , Matthew T.V. Chan , Flavia K. Borges , Kate Leslie , Emmanuelle Duceppe , María José Martínez-Zapata , Chew Yin Wang , Denis Xavier , Sandra N. Ofori , Michael Ke Wang , Sergey Efremov , Giovanni Landoni , Ydo V. Kleinlugtenbelt , Wojciech Szczeklik , Denis Schmartz , Amit X. Garg , Timothy G. Short , Maria Wittmann , Christian S. Meyhoff , Mohammed Amir , David Torres , Ameen Patel , Kurt Ruetzler , Joel L. Parlow , Vikas Tandon , Edith Fleischmann , Carisi A. Polanczyk , Andre Lamy , Raja Jayaram , Sergey V. Astrakov , William Ka Kei Wu , Chao Chia Cheong , Sabry Ayad , Mikhail Kirov , Miriam de Nadal , Valery V. Likhvantsev , Pilar Paniagua , Hector J. Aguado , Kamal Maheshwari , Richard P. Whitlock , Michael H. McGillion , Jessica Vincent , Ingrid Copland , Kumar Balasubramanian , Bruce M. Biccard , Sadeesh Srinathan , Samandar Ismoilov , Shirley Pettit , David Stillo , Andrea Kurz , Emilie P. Belley-Côté , Jessica Spence , William F. McIntyre , Shrikant I. Bangdiwala , Gordon Guyatt , Salim Yusuf , and P.J. Devereaux , on behalf of the POISE-3 Trial Investigators and Study Groups Metrics May 2023Volume 176, Issue 5Page: 725-726KeywordsBlood pressureHospital medicineHypertensionHypotensionPeri-operative medicineSurgery ePublished: 25 April 2023 Issue Published: May 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...